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Table 3 Recommendations for clinical application of dichotomies

From: A “messy ball of wool”: a qualitative study of the dimensions of the lived experience of obesity

Failure Double-Bind

General principle

• Most people with weight problems have a history of attempting weight loss strategies resulting in complex feelings of failure and learned helplessness.


• ‘Re-engineer’ the construct of ‘Failure’ as a double-bind (try & fail = failure (active); don’t try = failure (passive)). Moving from active failure to passive failure, yoyo weight loss/regain and behavioural arrest.

• Re-configure the construct of ‘success’ as non-quantified outcomes with emphasis on qualitative markers (improved fitness/mobility, a changed relationship with food).

Behavioural Health Consultation

• Debunk the notion of failure through modelling of weight-language

De-emphasise numerical weight-loss goals and reframe goals in qualitative terms.

• Positive reinforcement of the value of all attempts to change health behaviours and acknowledgment that unsuccessful attempts do not constitute failure

• Reduce learned hopelessness, improve self-efficacy, and address behavioural arrest.

Think-Feel Conflict

General Principle

• Rational control vs emotional control is central in volitional eating. Rational control manifests in what people think and say, while emotional control manifests in food choice and eating behaviour. Framing this conflict in terms of ‘control’ facilitates empowered responsibility for food choice and eating behaviours.


• Debunk the control conflict between conscious volitional eating and subconscious volitional eating – eating behaviour is always volitional behaviour

• Identify and examine the internal conflict created by the gap between thinking/wanting and feeling/behaving

Behavioural Health Consultation

• Complete an inventory of weight-related thoughts, feelings, and behaviours, identifying key conflicts

• Develop alternative weight-related health behaviours to reduce conflicts

• *Identify weight-retention motivations (e.g.self or relationship-sabotage) and refer for specialist intervention if required

Negative-Positive orientation

General principle

• Explanatory Style is a key element in the ways people interpret environmental factors, social experience and their own behaviour. A negative orientation closes the individual to possibilities for change and perpetuates learned helplessness, while a positive orientation opens the individual to new possibilities despite the lived constraints and limitations of circumstances


• Facilitate awareness of the role of psychological predisposition to negative or positive orientation

• Raise awareness of the role of predisposed orientation in perpetuating think/feel conflicts

Behavioural Health Consultation

• Facilitate improved capacity to self-identify negative orientation, its underlying causes and implications

• Expose and debunk negative orientation, facilitating positive orientation.

Impeding-Helpful Health Professional

General principle

• Health professionals either facilitate or impede access and engagement in weight-related behaviour change, depending on their level of knowledge and skill with weight-related intervention. Capacity building for health professionals to understand and engage people in weight-related health care is vital.


• Education and training in polarised dichotomies of obesity for front line health professionals to reduce knowledge gaps and increases the capacity to reinforce knowledge-as-insight.

Behavioural Health Consultation

• Training, education and resourcing of frontline Health Professionals in a responsive, integrated, ‘psychodietetic’ approach to weight-related intervention to build optimal response to weigh-related presentations [43].

• Emphasis on collaborative and integrated multidisciplinary support.

Knowledge as Gaps-Insight

General principle

• Knowledge is required to inform food choice and eating behaviour change, it cannot be assumed and should be provided in an iterative and communicatively competent manner – increased knowledge/autonomy/ relatedness leads to increased self-determination and intrinsic motivation.


• Providing adequate, consistent and iterative advice to facilitate insightful, reflective knowledge into motives for self-sabotage, weight gain and/or weight-retention.

• Identify and address psychodietetic knowledge gaps to empower sustainable food choice and eating behaviour change (e.g. emotional triggers, label-reading, viable ‘swaps’).

Behavioural Health Consultation

• Appreciation that eating behaviour is motivated and reinforced behaviour.

• Ensure knowledge is broad and holistic and entails self-reflective understanding of emotions, weight-retention motivations, and potential sabotage.

• Development of alternative strategies for self-soothing as behavioural substitutes.

Internal-External Orientation

General principle

• The permeating, fundamental dichotomy of ‘internal/external’ specifically identifies the role of intra-subjective preoccupation (e.g. habituated, ruminative, internally oriented self-appraisal or self-reflection) as a potentially causal factor in many eating behaviour profiles.


• Facilitate improved capacity to regulate orientation either intra-subjectively, inter-subjectively, or externally, through behavioural techniques and attention training strategies.

Behavioural Health Consultation

• Facilitate insight into, and shift of, habituated intra-subjective orientation to consciously directed external orientation.

• Facilitate insight into and decrease in weight/eating-related intra-subjective monologue Facilitate increased capacity to self-regulate emotion with non-food strategies (e.g. relaxation or substitution strategies).

• Facilitate increased capacity to regulate attention on benign stimuli (e.g. breath, sensation).

• Cognitive modification of counterproductive weight-related attributions.